Birth Certificates to Print

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					                               University Hospital
                        Birth Certificates & Vital Records
                                      1350 Walton Way
                                     Augusta, GA 30901
Dear Parent (s),

Please PRINT all of your responses neatly and accurately in the spaces below. Please enter the
name of the month in all date questions. The information you provide, except the CONFIDENTIAL,
CONTACT, and SOCIAL SECURITY information, will be shown on the certified copy of your
newborn’s Certificate of Live Birth, which is a legal document.

The information asked is collected under the authority of Georgia Code 31-10, Department of
Human Resources (DHR) Rules 290-1-3, Federal Law as well as any other applicable Georgia
Code and DHR Rules. If you have specific questions about completing this worksheet, please ask
the hospital birth certificate registration clerk. Information about Vital Records may be found on the
internet at www.georgia.gov or by calling the state Office of Vital Records or your local Vital
Records office at (706) 667-4334.

                           Forms Must Be Completed In INK

     Please Mail Or Bring This Worksheet With You To The Hospital

                      Please Sign The Worksheet On Page # 6

INSTRUCTIONS FOR NEW PARENTS:

   VITAL RECORDS REQUIRES THAT A BIRTH CERTIFICATE BE FILED ON EVERY CHILD
    WITH IN FIVE DAYS OF THEIR BIRTH.
   If you are unsure about an answer, Write or check “UNKNOWN” on the worksheet.
   These forms must be given to University Hospital Personnel at your OB Advisor (Pre-
    registration) Appointment or to the Birth Certificate Clerks when you are admitted to the hospital
    to deliver your baby.
   If the Mother is UNMARRIED, Please read the section under “Fathers Information” concerning
    paternity
   Please call with any questions
   The Birth certificate/Vital Statistic Office is open Monday – Friday 8am to 4pm

Thank You,
Blanca Corujo
Vital Records
Health Information Services
Third Floor
(706) 774-5859 or Extension 45859

                                           Page 1 of 6                           11/ 14/ 2010
YOUR BABY’S Information (PLEASE PRINT)
____________________________         _____________________
Baby’s First Name                    Middle
____________________________         ____________
Last                                 Suffix (JR, II, III)

Are you breast-feeding, or partially even breast-feeding your baby? ____ YES                 ____ NO


Social Security Number for This Child
If you answer YES to the question below, information will be taken from the Certificate of Live Birth
once the birth certificate is registered with the State Office of Vital Records. After the birth data is
sent electronically to the SSA you should receive a social security card for this child in the mail.
Allow at least 6 to 8 weeks from the child’s date of birth for the social security card to arrive. All
questions about social security cards should be directed to the Social Security Administration at 1-
800-772-1213.

Even if you select YES below, Georgia Vital Records can not guarantee your child will receive a
social security number. An SSN will not be issued for this child if the birth certificate cannot be
processed due to missing, incorrect or inaccurate information; wrong address; the child’s name is
incomplete; the certificate is received by Vital Records one year after the child’s date of birth; or the
SSA does not receive or process the information.


Are you requesting a Social Security Number for this child? (circle one)            Yes           No




This section is to be filled out by Hospital Staff:
 Date of Birth         Time of Birth           Sex (circle)       Name of the Facility/Hospital:

 ___/___/______        ___: ___ AM/PM           Male Female        University Hospital
 (month/day/year)


 Child’s Weight: ______lbs.                    Gestation (week’s)____

 Apgar score (5 min) ________                  If score is less than 6, 10 min score _____

 Single Birth_____ Twin A or B______ Triplet A, B, or C_____ Quad A, B, C, or D ______




                                              Page 2 of 6                          11/ 14/ 2010
Mother of Child Information (only)
______________________________________________________________________________
Mother’s First Name                      Mother’s Middle Name                      Mother’s Last Name

_______________________________________                                    (__ __ __) ___ ___ ___ - ___ ___ ___ ___
Mother’s Last Name at Birth (Maiden Name)                                   Mother’s Home Telephone Number

____________________/ __________/____________                              ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Mother’s Date of Birth (month name, day, 4-digit year)                     Mother’s 9 Digit Social Security Number

___________________________
Mother’s State or Country of Birth


MOTHER’S RESIDENCE ADDRESS
The complete address where you actually live.

___________________________________________________ _______________________________________
Street Number and Name                 Apt No.                    City/Town

____________________                     _____________                      ___________
County Name                              State or Country                  Zip Code + 4

INS IDE CITY LIMITS ? __Y es __No __Unknown                      Number of Y ears_____ Months___ at current residence

MOTHER’S MAILING ADDRESS (if different than the residenc e address shown above)

_____________________________________________________________________________________________
Street/Apt Number, Street Name/P.O. Box/RR Address City/Town     State/Country      Zip Code+4

MOTHER’S MARITAL STATUS : This information does not appear on your child’s birth certificate. The information has
to be entered into the database to register your baby legally. Giving false information about your marital status can delay
registration of your child’s birth certificate and cause legal problems in the future.

IS MOTHER MARRIED?               _____YES           ____ NO
If Unmarried, are parents signing a Pat ernit y Ack nowledgment ? _____ Yes _____ No

MOTHER’S OCCUP ATION:
What do you do for a living? ____________________________ Who do you work for? ______________________

Confidential Information
Are you Hi spanic or from Hi spanic origin/descent? ____No, Not Spanish/ Hispanic/Latin
____Yes, Puerto Rican ____Yes, Cuban          ____Yes, Other Spanish/ Hispanic/Latino (S pecify )________________
____Unknown             ____Refused

MOTHER’S RACE – Pleas e CHECK the race that best describes you:
____ White              ____ Black/African American     ____Asian Indian           ____Chinese
____Filipino            ____Japanes e            ____Korean                        ____Vietnamese
____ Native Hawaiian ____Samoan                  ____Guamanian or Chomorro
____American Indian or Alaska Native (Specify) _______________
____Other Asian (S pecify) ______________________
____Other Pacific Islander (S pecify ) ______________
____Other (S pecify) ___________________________
____Unknown             ____Refused


Is there any family member who has been deaf since childhood? ___ Yes              ___ No

                                                   Page 3 of 6                                  11/ 14/ 2010
Mother of Child Information (continued)
MOTHER’S EDUCATION

    A) Elementary/High School:
       CIRCLE the highest grade you completed. If foreign education, circle the grade most similar.
         None      1       2       3     4         5       6       7         8      9       10                 11         12

    B) CHECK the type of High School diploma you received.
       ___G.E.D.             ___ Diploma              ___Did not receive a diploma or G.E.D.

    C) College/University:
        A) CIRCLE the number of years of college you have complet ed. If outside the United States, circle the number
       of years that is most similar.
               1        2       3     4       Other number of years: ____          ____Did not attend college

    D) CHECK the highest degree you have obtained.
       ___ Associate’s ___ Bachelor’s ___ Master’s ___ Doctorate             ____ Did not obtain a degree




Questions concerning YOUR PREGNANCY

What did you weight before you were pregnant? ______Lbs.     ___Unknown
What did you weight when you came in to deliver your baby? ______lbs. ___Unk nown
How tall are you? ______

Did you get WIC food during this pregnancy? ___Yes ___No

Number of previous live births (do not include thi s child)
Number now living: _________ None____ Unknown_____                 Date of last live birt h ___/ ___/ ______
Number now dead: _________

Number of ot her outcomes (spontaneous or ectopic loss): _______ Date of outcome ___/___/______

Did you receive pre-natal care? ___Yes ___No

Date of first prenatal visit: ___/___/______
Date of last prenatal visit: ___/___/______

Total Number of prenat al visits: _______

Principal source of payment for this delivery__________________________(P rivate Insurance or Medicaid)

TOBACCO US E During this pregnancy, how many cigarettes did you smoke during an average day?

                                                   CIRCLE ONE SELECTION
         None    1   2   3   4   5   6   7     8    9 10 11 12 13 14            15   16    17   18    19       20   21+




                                                     Page 4 of 6                                  11/ 14/ 2010
Father of the Child Information (Only)

  Before completing this section, it is important to understand the following information:

  If the mother is MARRIED at any time between conception and the birth of the child, Georgia law
       REQUIRES the husband to be shown as the father of the child, unless a court has previously
       determined paternity.
  If the mother is UNMARRIED, the biological father’s name and information can be added to the
       birth certificate only after a Paternity Acknowledgment (PA) is completed and signed by both
       parents. It is recommended that a PA be completed while you are in the hospital, but the father
       must be present to sign the form and have valid photo ID.
  NOTE: If necessary, a PA may be completed after you leave the hospital at the county Vital
  Records office or at the State Office of Vital Records. If the mother is not married, the completion of
  a PA is strongly encouraged to obtain financial support for this child. Information about child
  support is available from the county Division of Family and Children’s Services office or call
  (404) 651-9361.



______________________________________________________________________
Father’s First Name        Father’s Middle Name                  Father’s Last      Suffix(Jr., I, II)

_________________________/ ____/_______________                     ___ __ __ - ___ ___ - ___ ___ ___ ___
Father’s Date of Birth (month name, day, 4-digit year)             Father’s 9 Digit Social Security Number

___________________________                                        (______) _______-______________
Father’s State or Country of Birth                                 Father’s Home Telephone Number

FATHER’S RESIDENCE ADDRESS

__________________________________________________________________________________________
Street Number and Name                 Apt No.            City/Town

____________________             ______________________            ____________
County Name                      State or Country                  Zip Code + 4

INSIDE CITY LIMITS? __Yes ___No ___Unknown                       Number of Years_____ Months___ at current residence

FATHER’S OCCUPATION:
What do you do for a living? _____________ _______________ Who do you work for? ______________________

Confidential Information
Are you Hi spanic or from Hi spanic origin/descent? ____No, Not Spanish/ Hispanic/Latin
____Yes, Puerto Rican ____Yes, Cuban          ____Yes, Other Spanish/ Hispanic/Latino (S pecify )________________
____Unknown             ____Refused

FATHER’S RACE – Please CHECK the race that best describes you:
____ White              ____ Black/African American     ____Asian Indian            ____Chinese
____Filipino            ____Japanes e            ____Korean                         ____Vietnamese
____ Native Hawaiian ____Samoan                  ____Guamanian or Chomorro
____American Indian or Alaska Native (Specify) _______________
____Other Asian (S pecify) ______________________
____Other Pacific Islander (S pecify ) ______________
____Other (S pecify) ________________________ ___
____Unknown             ____Refused

                                                   Page 5 of 6                                     11/ 14/ 2010
Father of the Child Information (continued)
FATHER’S EDUCATION

   E) Elementary/High School:
      CIRCLE the highest grade you completed. If foreign education, circle the grade most similar.

         None       1       2        3        4        5        6     7         8     9       10       11        12

   F) CHECK the type of High School diploma you received.

       ___G.E.D.                ___ Diploma                 ___Did not receive a diploma or G.E.D.

   G) College/University:
      A) CIRCLE the number of years of college you have completed. If outside the United States, circle the
          number of years that is most similar.

                1       2       3        4        Other number of years: ____       ____Did not attend college

   H) CHECK the highest degree you have obtained.
      ___ Associate’s ___ Bachelor’s ___ Master’s ___ Doctorate           ____ Did not obtain a degree




I have reviewed the information I have entered above and to the best of my knowledge it is accurate and
correctly spelled.

____________________________________________________________                    ________/ _________ /___________
 (Signature of Mother, Father, or Informant)                                     (mont h name, day, 4 digit year)

Print Informant’s name if not mother or Father of this child: __________________________________________
                                                                   First        Middle       Last
Informant’ s relationship to the child: ____________________________________

A Vital Records certified copy of this child’s birth certificate WILL NOT automatically be sent to the
mother. The parent(s) must apply for a certified copy of the birth certificate at the Vital Records office
located in the county or State where the child was born. The hospital birth certificate registration clerk
can furnish the location of the county office. There is a $10.00 fee for the first copy and a $5.00 fee for
each additional copy of the same certificate ordered at the same time. Allow at least 6 to 8 weeks before
you request a certified copy of this child’s birth certificate.


                                                  Page 6 of 6                               11/ 14/ 2010

				
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